Involutional or Senile Entropion

Etiology

• Definition: Inward rotation of the eyelid margin with direction of the lashes or keratinized lid margin against the ocular surface, leading to inflammation and keratitis
• Both the upper and lower eyelid can be affected, although involvement of the lower eyelid is much more common. Histopathology of elderly cadaveric eyelids demonstrated override of the preseptal orbicularis oculi over the pretarsal muscle in the lower lid, but rarely in the upper lid (Kakizaki, Clin Ophthalmol 2009).
• Three commonly described anatomic factors contributing to involutional entropion:
• Lower lid horizontal laxity allows the inferior border of the tarsus to rotate outward
• Disinsertion, atrophy or dehiscence of lower eyelid retractors (capsulopalpebral fascia) destabilizes the inferior tarsus
• Preseptal orbicularis overriding pretarsal orbicularis muscle
• Histopathology (Damasceno, Ophthal Plast Reconstr Surg 2011)
• With increasing age, the composition of the tarsus changes from mainly collagenous fibers to elastic fibers causing increased horizontal eyelid laxity.
• Decrease in orbital fat volume with age can increase enophthalmos and relative eyelid laxity, allowing for greater orbicularis override.

Epidemiology

• Occurs in up to 2.1% of the elderly population (1.9% men and 2.4% women), with significant tissue laxity (Damasceno, Ophthal Plast Reconstr Surg 2011).
• Females can be more susceptible due to smaller tarsal plates than males (Bashour, Ophthal Plast Reconstr Surg 2000).
• Patients with involutional entropion have a 4-year mortality of 30% (Wright, Br J Ophthalmol 1999).

History

• Chronic foreign body sensation or irritation
• Pain
• Red eye
• Epiphora due to irritation or lash touch
• Discharge
• Decreased or blurry vision

Clinical features

• Lower eyelid margin rotated inward against cornea (Figure 1) and conjunctiva causing corneal thinning, vascularization, and scarring
• Superficial keratopathy
• Occasionally bacterial keratitis
• Chronic cases can lead to corneal ulceration or perforation.

Figure 1. Entropion left lower lid. Courtesy Michael J. Hawes, MD.

Testing

• Rule out trichiasis, distichiasis, and epiblepharon, in which eyelid margin itself is in normal anatomic position against globe surface.
• If present, these can also cause secondary spastic entropion.
• Assess corneal status specifically for corneal abrasions, scarring, thinning, or neovascularization.
• Rule out other causes of ocular surface irritation or infection that can predispose to spastic entropion.
• Ascertain the absence of cicatricial changes in the posterior lid and/or fornix.
• Examine the fornix for dehiscence of the inferior retractors (capsulopalpebral fascia).
• Measure horizontal laxity of the eyelid, including assessment of the medial and lateral canthal tendons.

Testing for staging, fundamental impairment

• Snapback and eyelid distraction test to assess for horizontal lid laxity
• Lower lid excursion in down-gaze to measure lower lid retractor function: Limited lower lid movement in downgaze or obstruction of the pupil by the lower lid would confirm dehiscence of the inferior retractor layer from the inferior tarsal border.
• Deeper inferior fornix or more prominent subconjunctival fat on the affected side would suggest dehiscence of the inferior retractors because the retractors also have fibers that insert into the inferior fornix in addition to the insertions into the inferior tarsus and anteriorly into the orbicularis and skin to form the lid crease.
• A thick, white, horizontal band in the inferior fornix on exam indicates the leading edge of the dehisced inferior retractors.

• Elderly (Damasceno, Ophthal Plast Reconstr Surg 2011)
• Lower eyelid horizontal laxity
• Prior intraocular surgery or procedures (i.e., use of lid speculum)
• Longer axial ocular globe length might be more common in patients with ectropion (23.5 mm) than entropion (22.7 mm) (p = 0.0008). Entropion was also more common in females (p = 0.03) (Jyothi, Ophthal Plast Reconstr Surg 2012).

• Spastic entropion
• Can be elicited by forcefully closing the eyelids to induce an overriding orbicularis muscle
• Cicatricial entropion
• Rule out presence of fornix shortening, symblepharon, posterior or bulbar conjunctival scarring
• Trichiasis without entropion
• Distichiasis
• Misdirected lashes, often related to meibomian gland disease or local scarring
• Aberrant lashes
• Epiblepharon
• Presence of a horizontal roll of lower eyelid skin and orbicularis muscle that pushes the lashes against the cornea
• Most commonly occurs in children of Asian descent
• Can improve with age (and enlargement of the nasal bridge and midfacial bones) without surgery

Medical therapy

• Medical therapy is useful as temporizing measures for patients waiting for surgery, or for those unable to undergo surgical correction due to medical concerns.
• Ocular lubrication and/or bandage contact lenses can be used to protect the cornea from lashes.
• Eyelid taping: Secure a 3-cm tape strip about 0.5 cm below the central lower eyelid and gently distract in a lateral and slightly elevated position to evert the margin to normal position (Stevens, Comm Eye Health 2012). Technique should be demonstrated to the patient to avoid incorrect lid position or ocular irritation from the tape edge.

• Cyanoacrylate glue can be placed in the lower lid crease with a 20-gauge cannula. 7/10 patients had continued adhesions 1 week after application (Puri , Eur J Ophthalmol 2001). No major ocular or dermatological complications were recorded.
• Octyl-2-cyanoacrylate liquid bandage has been used to help reposition the lids with placement along the malar folds. 15/15 eyelids had substantial symptomatic improvement. The mean duration effect was 3 days. No major ocular or dermatological complications were recorded (Osaki, Arq Bras Oftalmol 2010).
• Botulinum toxin can be administered into the lateral preseptal orbicularis at several sites to counteract the orbicularis override. Symptomatic improvement and anatomical success using 20 units has been reported in 33/35 eyelids, with a mean duration of effect of 12.5 weeks, correlating inversely with the amount of lower lid laxity (Steel, Eye 1997). Complications were few, including increased epiphora and diplopia that resolved after orbicularis function returned. Iatrogenic ectropion might also be seen, particularly with higher doses and significant underlying horizontal laxity.
• Preliminary studies with the CO₂ laser have used 200 mJ of energy to the lower lid and preorbital area, sparing the subciliary region, and 200 mJ of energy to the lash line. 4/5 eyelids had symptomatic relief and no anatomical recurrence 5–21 months later. Improvement was presumably secondary to skin shrinkage (Babuccu, Lasers Med Sci 2012).

Surgery

Temporizing surgical procedures

• Quickert-Rathbun rotational sutures
• Indications: For correction of lower eyelid involutional entropion when a more definitive procedure is not practical, such as if patient is a poor surgical candidate due to significant medical comorbidities.
• Contraindications: Not effective for cicatricial entropion, distichiasis or aberrant lashes. Can worsen lower eyelid retraction.
• Preprocedure evaluation:
• Determine that it is reasonable to perform temporizing procedure rather than moving directly to definitive procedure.
• Evaluate patient for ocular surface disease (i.e., surface keratopathy, corneal infiltrates) and etiology of entropion.
• Cicatrizing etiologies can demonstrate shortened fornices, symblepharon, and scarred posterior tarsal conjunctiva.
• Horizontal laxity should be evaluated, as significant laxity can predispose to secondary ectropion after Quickert sutures.

• Technique:
• Performed in office setting without intravenous sedation
• Apply topical proparacaine to ocular surface. Corneal protector can be used.
• Inject local anesthesia (1%–2% lidocaine with 1:100,000 units epinephrine) to lower lid and fornix
• Place absorbable double-armed horizontal mattress sutures from the inferior cul de sac posteriorly to exit skin just below the lashes.
• Each arm of the suture is typically passed 3-4mm apart to prevent horizontal wadding of tissue.
• Conjunctival entrance of the suture should be slightly deeper than the anterior skin exit to create the everting effect. Deeper pass in the inferior cul de sac also elevates the dehisced inferior retractors back towards the inferior tarsus before exiting the skin surface.
• Tie arms of suture on skin, and visualize the lid margin everting to proper anatomic position. If suture is tied too tightly, the margin might evert excessively to become a secondary ectropion.
• 3 horizontal mattress sutures can be placed, 1 each medially, centrally and laterally.
• Use permanent or absorbable (i.e., chromic) sutures, 4-0 through 6-0 are acceptable.

• Preventing and managing treatment complications
• Placement of sutures too deep in cul de sac cause vertical shortening of the lid and causes lid retraction
• Placement of suture arms too far apart causes wadding of lid horizontally and can cause tarsal warping
• Excessive tightening of the sutures on the skin might cause ectropion, particularly in the setting of preexisting horizontal eyelid laxity
• If this occurs, perform selective and/or early suture removal.
• Suture abscesses are not uncommon.
• Treat with antibiotic ointment; oral antibiotic if cellulitis develops.
• Sutures can be removed after 2–3 weeks if they have not resorbed.
• Procedure relies on scar tract of suture to maintain lid position when sutures are absorbed.
• Scheepers et al. (Ophthalmology 2010) found a high rate of recurrence up to 21% (6/29 patients) with the use of everting sutures alone
• Follow-up care
• Effect of the procedure can be temporary.
• Recurrences should be addressed with more definitive procedures that address coexisting anatomic pathology.
• Patient instructions
• Routine wound care
• Ice or cold compresses post-procedure to minimize bruising
• Avoid strenuous activity.
• Apply topical ointment to external sutures until dissolved.
• Remove sutures in 2–3 weeks if still present.
• Eyelid skin cautery
• Careful thermal cautery to the anterior lamella can result in tightening of the skin to induce anterior rotation of the lid margin.
• Cicatricial ectropion can result if too aggressive.
• Scarring and pigmentation issues can persist.

Definitive surgical correction

• Lower lid retractor advancement/reattachment (AKA Jones retractor plication)
• Indications: Involutional entropion without significant horizontal laxity. The procedure primarily addresses disinsertion of the lower lid retractors. Secondarily, the surgical scar limits overriding of the orbicularis. This procedure alone does not address horizontal eyelid laxity. This procedure is typically combined with a horizontal lid tightening procedure in most cases of involutional entropion.
• Contraindications: Cicatricial entropion
• Preprocedure evaluation: Assess cause of entropion and appropriateness for retractor repair.
• Clinical signs of decreased lower lid movement in downgaze, deeper inferior fornix, and a recessed white horizontal leading edge of the retractors can be seen
• Technique
• Incise skin at subciliary line or at inferior tarsal margin.
• Dissect past orbital septum and inferiorly to identify the dehisced lower lid retractors.
• Attach retractors to inferior tarsal margin with several sutures of 6-0 vicryl to repair the retractor disinsertion component of the entropion.
• Close orbicularis muscle layer and skin so that subsequent scar prevents overriding orbicularis.
• Many surgeons prefer a transconjunctival approach below inferior tarsal edge.
• A comparison of the internal transconjunctival versus the external subciliary approach of 49 eyes showed similar success rates. Although not statistically significant, internal repair resulted in a slightly higher recurrence rate, whereas external repair had more postoperative ectropion, most probably attributable to scarring of the anterior lamella and failure to perform lateral canthal suspension concurrently (Ben Simon, Am J Ophthalmol 2005).
• Preventing and managing treatment complications
• Recurrence rate varies depending on the surgical technique.
• The recurrence rate when combined with horizontal tightening at the lateral canthus was found to be 1.6%. Recurrence rates of inferior retractor repair alone and lateral tarsal strip alone were 33% and 22% at 36 months (Rougraff, Ophthal Plast Reconstr Surg 2001).
• Recurrence is associated most often with lack of correction of horizontal laxity
• To address both the horizontal and vertical lower eyelid laxity, Ranno et al. (Eur J Ophthalmol 2014) studied the use of Jones retractor plication in conjunction with lateral tarsal strip. The recurrence rate was five times more in a 2-year follow up period using a Jones retractor repair alone (10/60), compared to when retractor repair was combined with a tarsal strip (2/55).
• Failure to recognize other elements of pathology encountered in involutional entropion
• Lower lid retraction or ectropion caused by aggressive shortening of retractors during reattachment or failure to identify the retractors, imbricating the septum instead
• Lateral lid tightening (e.g., lateral tarsal strip procedure), usually in conjunction with retractor reinsertion
• Indications: For correction of horizontal laxity, tarsal laxity, lateral canthal tendon laxity
• Contraindications: Typically not effective alone for correction of entropion, cicatricial entropion, or lower eyelid retraction, and can require adjunctive procedures
• Technique:
• Apply topical proparacaine to ocular surface.
• Inject local anesthesia (1%–2% lidocaine with 1:100,000 units epinephrine) to canthus.
• Incise skin at lateral canthal angle for 5–10 mm.
• Incise the inferior limb of the lateral canthal tendon, which will release the lower lid from the orbital rim.
• Release the lateral attachments of the orbitomalar ligament from the lateral orbital rim if needed to better release the lower lid.
• Place lower lid at the desired height and tucked into the orbital rim near Whitnall’s orbital tubercle and note the location on the lower lid margin where it meets the upper lid’s lateral edge; this marks the length of tarsal strip to be created.
• Excise or cauterize the epithelium for the length of the tarsal strip, taking care to avoid removing tarsal plate.
• Divide the lid margin into an anterior and posterior lamella, with the posterior lamella composed of the tarsus and the conjunctiva for the length of the tarsal strip.
• Remove the eyelash follicles for the length of the tarsal strip.
• If there is excess tarsal strip that would cause too much bunching, conservatively trim remaining tarsal strip.
• Secure tarsal strip with a 4-0 or 5-0 absorbable or nonabsorbable suture using a P-2, OPS-5, or P-3 needle to the periosteum several millimeters inside the orbital rim at slightly above the desired height.
• Watch for secondary retraction of the lower lid if the sutures are tied too tightly.
• The placement of the periosteal suture should reposit the lateral lower lid about 2 mm above the level of the medial canthal position, with the lateral canthal height compared to the opposite eyelid for symmetry.
• Reform lateral canthal angle for a sharp angle contour with a buried interrupted suture using 6-0 or 7-0 vicryl to close the upper and lower lid margins; failure to reapproximate the angle can often result in a rounding or webbed appearance to the lateral canthus or override of one lid over the other.
• Close the orbicularis muscle and skin edges
• Preventing and managing treatment complications
• Recurrence of laxity
• Olver et al. (Ophthalmology 2000) performed lateral tarsal strip with diagonal tightening of the orbital septum and lower lid retractors on 44 patents. After one year follow up, cure rate was 85% (36/44). Anatomic recurrence up to two years after surgery occurred in 6 patients. The use of the lateral tarsal strip and everting sutures from the same group was found to have a 98% success rate with no recurrence after one year (53/54).
• Dehiscence of periosteal attachment
• 1–3 sutures can be used to better secure the tarsal strip to the periosteum.
• Avoid multiple passes through the periosteum that weakens the integrity of the periorbita and thus predisposes to recurrence
• If periosteum appears attenuated or repeat surgery is indicated, a bone tunnel/plate/ anchor suture can be used to secure the tarsal suture
• Webbing, rounding, or ankyloblepharon of the lateral canthus can be avoided by reapproximating the upper and lower lid margins with a buried suture to reestablish the sharp angle
• Lower lid retraction can occur from shortening the tarsal strip too much or overly tightening the sutures, both of which can cause the lower lid to slide inferiorly. Globe proptosis, or negative vector relationship to the orbital rim, can also predispose to lower lid retraction, so perform horizontal tightening judiciously.
• Canthal angle dystopia can occur if the lid is placed too high or too low into the periorbita. This can be avoided by simulating the desired height and position during surgery before placing the periosteal suture and comparing the position with the opposite eye prior to cutting the suture.
• Quickert modification of Wies — horizontal shortening with margin rotation — 4-snip procedure
• Indications: Involutional entropion with horizontal laxity. This procedure theoretically addresses all 3 of the underlying components of involutional entropion (horizontal laxity, retractor disinsertion and overriding orbicularis).
• Contraindications: Cicatricial entropion or failure to repair lateral canthal laxity will result in shortening of the horizontal palpebral aperture and possible rounding of the lateral canthal angle.
• Alternatives: Wies procedure, lower lid retractor repair, temporary rotation sutures, or lateral lid shortening, with or without Quickert rotation sutures
• Technique
• Inject local anesthesia (1%–2% lidocaine with 1:100,000 units epinephrine) to lower eyelid.
• Create a vertical incision through full-thickness margin of the lateral 1/3 of tarsus (1st snip).
• Make a full-thickness horizontal incision medially along inferior tarsal margin to a point inferior to the punctum (2nd snip).
• Make a full-thickness horizontal incision laterally along inferior tarsal margin to lateral canthus (3rd snip).
• Overlap medial and lateral flaps to determine laxity and excise excess from the longer medial flap (4th snip).
• Perform standard lid margin repair to approximate flaps (corrects horizontal laxity). Be sure to close tarsal plate with additional partial thickness horizontal 6-0 vicryl sutures to reapproximate the full height of the tarsal plate to avoid collapse of the lid margin. Without closure of the rest of the tarsus, the tarsal edges gape open and the lid margin becomes notched.
• Place horizontal mattress sutures from conjunctiva and retractors below horizontal incision to exit on skin below lashes (reinserts retractors to inferior tarsal edge).
• Close orbicularis muscle and skin edges in layered fashion (scar prevents overriding orbicularis).
• Preventing and managing treatment complications
• Recurrence can happen, although less commonly than with Quickert sutures.
• Suture granuloma from rotation sutures
• Lower lid retraction if mattress suture goes too far into inferior fornix
• Lid margin notching if lid margin is not reapproximated well, or if the rest of the tarsus is not closed inferior to the margin to provide vertical support to the margin
• Weis procedure (eyelid margin rotation)
• Indications: Treatment of mild to moderate lower lid entropion using margin rotation via fracturing of the tarsal plate
• Technique:
• Inject local anesthesia (1-2% lidocaine with 1:100,000 units epinephrine) to lower eyelid.
• With a surgical marking pen, mark the horizontal incision about 3 mm below the eyelash line to avoid the marginal artery that could result in lid margin sloughing.
• Place protective corneal shield on the ocular surface.
• Place a 4-0 silk traction suture through the gray line of the central lower lid for superior traction; alternatively, an assistant can grasp the lid margin with toothed Adson forceps and retract the lid superiorly.
• Cut the marked horizontal incision through full-thickness eyelid with a 15-blade scalpel from the inferior punctum toward the lateral canthal angle; protect the ocular surface be all times with a jaeger plate.
• The horizontal incision can also be made partial-thickness through skin and orbicularis muscle with the blade and the posterior lamella/conjunctiva incised with Westcott scissors, again taking care to avoid injury to the marginal artery at the inferior border of tarsus.
• The lid margin should still be connected to the rest of the eyelid medially and laterally.
• Rotate margin anteriorly away from the ocular surface with 3 sets of 4-0 double-armed silk or chromic gut sutures. Place sutures as a horizontal mattress through the conjunctiva and residual inferior tarsus on the lower edge of the incision, with both arms of the sutures passed outward through the upper incision through the pretarsal orbicularis muscle and skin to exit on the skin 2–3 mm from the eyelid margin. Place 3 sets evenly in the central, medial, and lateral lid, with the sutures tied on the skin just below the lash line.
• The amount of entropion correction, or eyelid margin rotation, is determined by the position of suture exit relative to the eyelashes.
• Prior to tying the mattress sutures, close the skin incision with 6-0 fast absorbing plain gut suture.
• Preventing and managing treatment complications
• Eyelid margin sloughing can occur if the incision is placed at the inferior border of tarsus and compromises the marginal artery.
• Overcorrection, or iatrogenic cicatricial ectropion, can be avoided by placing incision no more than 3–4 mm from the eyelid margin and avoiding placing the sutures closer than 2–3 mm from the eyelash line.
• Early overcorrection can be improved with early removal of rotating sutures.
• Horizontal tightening might be necessary.
• More severe cases require release of cicatricial bands and inverting sutures or spacer grafts.

• Recurrence minimized by addressing all anatomic etiologies
• Wound dehiscence minimized by appropriate tissue closure
• Infection avoided with sterile technique and appropriate wound-care
• Hematoma or hemorrhage avoided by discontinuing aspirin or blood-thinning medications/herbal supplements prior to surgery, and avoiding strenuous activity postoperatively for one week
• Significant expanding hemorrhage that risks vision might require urgent open-incision evacuation.

• Corneal irritation from constant irritation of lashes against ocular surface
• Corneal scarring
• Corneal ulcer (Musch, Arch Ophthalmol 1983)
• Vision loss

• Detailed wound care instructions
• Follow up for recurrence, as there can be a high rate of incidence based on the procedure performed. Procedures that address more of the underlying etiologies of involutional entropion have lower failure rates. 

By 1972 when Jones et al. reported their procedure (Am J Ophthalmol 1972), more than 80 surgical procedures were already described for entropion repair, most notably:

• 1938: horizontal tightening of the orbicularis muscle with stabilization of the lower lid retractors (Wheeler J, Trans Am Ophthalmol Soc 1938)
• 1954: tightening the lower lid retractors to improve vertical lid laxity (Wies, J International College of Surgeons 1954)
• 1963: directly tightening the lower lid retractors to improve vertical lid laxity (Jones et al., Am J Ophthalmol 1963)
• 1969: vertical shortening and horizontal shortening to create a wedge excision (Tenzel, Arch Ophthalmol 1969)

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